CENTRO
LEGAL g!~!

California
Collaborative for
Immigrant Justice
Colaborativo de CaLi fornia de Justicia para
1nm1grantes

February 25, 2020
Via Email and US Priority Mail
Joseph V. Cuffari
Inspector General
Department of Homeland Security
245 Murray Lane SW
Washington, DC 20528

Cameron Quinn
Officer for Civil Rights and Civil
Liberties
Department of Homeland Security
245 Murray Lane, SW
Washington, DC 20528
CRCLCompliance@hq.dhs.gov

David Jennings, Field Office Director
c/o Leslie Ungerman, Chief Counsel,
Office of the Principal Legal Advisor,
San Francisco
U.S. Immigration and Customs
Enforcement
100 Montgomery Street, Suite 200
San Francisco, CA 94104
Leslie.J.Ungerman@ice.dhs.gov

Nathan Allen, Warden
Mesa Verde ICE Processing
Facility
c/o Susan Coleman
Burke, Williams, & Sorenson LLP
444 South Flower Street, Suite
2400
Los Angeles, CA 90071
scoleman@bwslaw.com

Re: Complaint for Violations of Civil, Constitutional, and Disability
Rights of Choung Woong Ahn, A# 042-028-791, at Mesa Verde
ICE Processing Facility
I.

Introduction

Disability Rights California (DRC), Centro Legal de la Raza (Centro Legal),
and the California Collaborative for Immigrant Justice (CCIJ) submit this
complaint in response to the death of Choung Woong Ahn, who died by
suicide on May 17, 2020 when placed in an isolation cell in conditions akin

Complaint for Violations of Civil, Constitutional, and Disability Rights
Choung Woong Ahn

Page 2

to solitary confinement1 at the Mesa Verde ICE Processing Facility (Mesa
Verde). Mesa Verde is operated by the GEO Group (GEO) under a contract
with Immigration and Customs Enforcement (ICE).
DRC is the agency designated under federal law to investigate and litigate
violations of the civil, constitutional, and disability rights of Californians with
disabilities like Mr. Ahn.2 Centro Legal is one of the largest providers of
legal services to detained indigent immigrants in California, and
represented Mr. Ahn in petitioning for release from ICE detention, speaking
regularly with him and his family before his death.3 CCIJ leads the
collection and analysis of data on the detained immigrant population in
Northern and Central California, documenting detention conditions related
to health, medical care, and solitary confinement during the COVID-19
pandemic, among other things.
Based on our investigation into Mr. Ahn’s death conducted to date, we write
to express grave concern that ICE and GEO repeatedly violated federal
disability law, the U.S. Constitution, and binding detention standards
throughout Mr. Ahn’s time at Mesa Verde and ultimately causing his death.
Among other things, the evidence shows that ICE and GEO repeatedly
failed to provide Mr. Ahn with adequate and timely medical care and mental
1

Authorities deploy “solitary confinement” “for a variety of reasons, only some of
which are officially acknowledged,” and use “many different names and acronyms” to
describe the practice. Craig Haney, et al., Consensus Statement from the Santa Cruz
Summit on Solitary Confinement and Health, 115 Northwestern L. Rev 335, 335 (2020)
(hereinafter, the Medical Consensus Statement). At baseline, however, experts define
solitary confinement as “in-cell confinement for upwards of twenty-two hours a day” with
“depriv[ation] of meaningful social contact for lengths of time” including even “very brief
periods.” Id. at 335-337 (explaining that solitary confinement also frequently deprives
detained people of access to “other aspects of everyday prison life that are essential to
health and rehabilitation,” such as “positive environmental stimulation, meaningful
recreation, programming, treatment, [and] contact visits,” among other things). ICE and
GEO, in court filings and public statements, have used various terms to describe the
isolation environments in which Mr. Ahn died at Mesa Verde, (e.g., medical isolation,
administrative segregation, and restrictive housing, among others). However, the
Medical Consensus Statement’s definition set out above fits most squarely with the
conditions in which Mr. Ahn died: extended in-cell confinement and deprivation of social
contact. This complaint uses the term “solitary confinement.”
2
DRC does not represent Mr. Ahn’s estate in any potential litigation related to his
death.
3
Centro Legal represented him in release advocacy, but not removal proceedings.

Complaint for Violations of Civil, Constitutional, and Disability Rights
Choung Woong Ahn

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health treatment, leading to his mental and physical deterioration; failed to
adequately screen him, assess his risk of self-harm, and implement
appropriate suicide-prevention protocols; segregated him on the basis of
his disabilities and denied him reasonable accommodations, in violation of
federal disability law; unlawfully placed him in segregation despite
assessing his mental illness as “severe” and concluding that he showed a
“high risk of suicide”; and while in segregation, failed to properly monitor
him or provide adequate mental health care to prevent his death. These
findings warrant immediate investigation by the Office of Civil Rights and
Civil Liberties (CRCL) and the Office of the Inspector General (OIG).
To prevent needless additional suffering and death, we request that CRCL
and OIG:
(1) conduct an independent and comprehensive investigation into the
circumstances at Mesa Verde that resulted in Mr. Ahn’s death,
including an evaluation of medical and mental health care
provided to him, the tracking and accommodation of his
disabilities, and his placement in solitary confinement;
(2) conduct an independent and comprehensive investigation into the
use of segregation (administrative, medical, and disciplinary) at
Mesa Verde. The investigation should evaluate facility practices
regarding the purpose and duration of segregation, as well as
practices relating to medical and mental health assessments,
particularly during the COVID-19 pandemic;
(3) publish the results of your investigation so that Congress and the
state of California can take appropriate action to hold ICE and
GEO accountable for the violations of law that led to Mr. Ahn’s
death, address ongoing harms arising from the improper use of
solitary confinement in California facilities, and prevent future
deaths like Mr. Ahn’s.
Further underscoring the need for an independent investigation by OIG and
CRCL, ICE initially reported false and misleading information to Congress
and the public about the events leading up to Mr. Ahn’s death. As a
growing number of federal courts have now found in the context of the
COVID-19 pandemic, ICE and GEO cannot be trusted to protect the health

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Choung Woong Ahn

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and safety of people in detention, and here, too, they have no incentive to
meaningfully investigate themselves.4 Indeed, new evidence has emerged
showing that Mr. Ahn’s case illustrates a much deeper systemwide
problem, demanding immediate action by OIG and CRCL.5
4

In litigation challenging the constitutionality of conditions at Mesa Verde during
the COVID-19 pandemic, for example, a federal court recently expressed regret for
having trusted ICE’s promises to self-correct, finding that “from the start of the public
health crisis until now, the conduct of the key ICE and GEO officials in charge of
operations at Mesa Verde has been appalling.” See Zepeda Rivas v. Jennings, Order
Granting Motion for Second Preliminary Injunction, No. 20-cv-02731-VC (N.D. Cal. Dec.
3, 2020) (Dkt. 867) at 2-3 (hereinafter, Zepeda Rivas Second Preliminary Injunction)
The court detailed how officials in ICE ERO’s San Francisco Field Office repeatedly
showed deliberate indifference to the lives of detained people at Mesa Verde, noting
that ICE officials even gave “false testimony several times in these court proceedings on
matters of importance” and otherwise “obstructed the proceedings” in their testimony.
Id. at 2. Describing Respondents’ management of Mesa Verde as “abominable,” the
court concluded that the defendant ICE and GEO officials “cannot be trusted to conduct
themselves responsibility as it relates to the safety of the detainees.” Id. at 3, 6; see also
Hernandez-Roman v. Wolf, Adelanto Population Reduction Order, No. 5:20-cv-00768TJH-PVCT (C.D. Cal. Oct. 15, 2020) (Dkt. 686) at 2-3 (noting that ICE “provided the
Court with a blaring example of its dishonesty,” which prompted the “court to re-assess
the information the Government has provided it in this case, as well as the arguments
the Government has made,” and further expressing regret for having “given the
Government and its counsel the benefit of the doubt” as to their self-reporting); Fraihat
v. ICE, Order Granting Motion to Enforce, No. 5:19-cv-01546-JGB-SHK (C.D. Cal. Oct.
7, 2020) (Dkt. 240) at 8-13, 18 (finding that ICE has “substantially failed to comply” with
court orders to ensure minimum constitutional conditions for detainees, and decrying
ICE’s “pattern of noncompliance or exceedingly slow compliance” requiring increased
court supervision); Zepeda Rivas v. Jennings, No. 20-cv-02731-VC, 2020 WL 3055449
at *4 (N.D. Cal. June 9, 2020) (hereinafter, Zepeda Rivas First Preliminary Injunction)
(ordering ICE to close intake at Mesa Verde and commenting that ICE’s conduct “since
the pandemic began ha[s] shown beyond doubt that ICE cannot currently be trusted to
prevent constitutional violations at [Mesa Verde] without judicial intervention.”).

5

In January 2021, a California Department of Justice report characterized
improper use of solitary confinement and restrictive housing as a “systemic” issue in
California’s immigrant detention centers. See Attorney General Xavier Becerra, The
California Department of Justice’s Review of Immigration Detention in California (Jan.
2021), https://oag.ca.gov/sites/all/files/agweb/pdfs/publications/immigration-detention2021.pdf. The report cataloged cases, across multiple detention centers, of detained
people housed in restrictive settings despite suffering from a mental health condition,
and despite evidence that isolation worsened their symptoms. See id. at 24-28.

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Choung Woong Ahn

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In preparing this complaint, DRC and Centro Legal reviewed Mr. Ahn’s
clinical and detention records from Mesa Verde, medical records from
Mercy Hospital, 911 records, police reports from the Bakersfield Police
Department, and other legal documents and filings.6 Additionally, Centro
Legal interviewed over sixteen witnesses at Mesa Verde who interacted
with Mr. Ahn in the days and weeks leading up to his death, as well as Mr.
Ahn’s brother, Young Ahn, who spoke with him on the day of his death. In
addition, CCIJ and Centro Legal collected and analyzed data on conditions
at Mesa Verde, especially regarding medical and mental health treatment
and the use of segregation during the COVID-19 pandemic, based on
interviews conducted with over 130 detainees since February 21, 2020, the
date of Mr. Ahn’s detention at Mesa Verde. This evidence forms the basis
of this complaint.
II.

Factual background

Mr. Ahn was a 74-year-old South Korean immigrant who was detained at
Mesa Verde from February 21, 2020 until his death there on May 17,
2020. Mr. Ahn first came to the United States in 1988, and was admitted
as a lawful permanent resident in San Francisco, California. On February
21, 2020, the state of California allowed ICE Enforcement and Removal
Operations (ERO) to take custody of Mr. Ahn upon his release from
Solano State Prison in Vacaville, California.
Mr. Ahn was a qualified person with a disability under Section 504 of the
Rehabilitation Act7 and under the applicable regulations promulgated by
the Department of Homeland Security (DHS) governing non-discriminatory
treatment of people with disabilities.8 Mr. Ahn had a history of suicide
6

DRC did not review or disclose any of the information obtained using our federal
and state access authority for this complaint.
7
See Rehabilitation Act of 1973, § 504, Pub. L. No. 93-112, 87 Stat. 355; 29
U.S.C. § 705(20).
8
6 C.F.R. § 15.1 (“The purpose of this part is to effectuate section 504 of the
Rehabilitation Act of 1973 ('Section 504'), as amended by section 119 of the
Rehabilitation, Comprehensive Services, and Developmental Disabilities Amendments
of 1978, which prohibits discrimination on the basis of disability in programs or activities
conducted by Executive agencies. The provisions established by this part shall be
effective for all components of the Department, including all Department components

Complaint for Violations of Civil, Constitutional, and Disability Rights
Choung Woong Ahn

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attempts, a diagnosis of unspecified depressive disorder, and numerous
physical disabilities including hypertension, type 2 diabetes, and severeheart related issues. These conditions interfered with his ability to function
on a day-to-day basis.
Upon his arrival at Mesa Verde in February 2020, Mr. Ahn reportedly
denied having a history of suicidal ideations or mental illness, a common
response where someone fears being placed in suicide-watch isolation.9
However, staff did not conduct an adequate review of Mr. Ahn’s previous
incarceration records. Over the following three months, medical staff at
Mesa Verde began to document more information regarding Mr. Ahn’s
history of suicide attempts in detention, his feelings of depression, and his
previous mental health treatment. His mental and physical health together
started to decline.
1. As Mr. Ahn’s physical and mental state deteriorated, ICE
and GEO documented his history of severe mental illness
and prior suicide attempts in custody, but ignored
mounting evidence suggesting ongoing suicidal ideation.
On March 12, 2020, Mr. Ahn reported experiencing shortness of breath and
chest pain, and was admitted to the emergency department of Mercy
Hospital in Bakersfield, California, where he received emergency surgery to
remove a mass on his lung. Mr. Ahn understood his diagnosis at the time to
be lung cancer. Hospital records obtained after his death show that he was
supposed to return shortly for follow up care and to confirm the biopsy
results. But ICE delayed authorizing and scheduling the appointment for
months. Ultimately, Mr. Ahn died by suicide before he received follow-up
care for the mass on his lung.
Aware that his medical conditions rendered him vulnerable to severe illness
or death if he were to contract COVID-19, Mr. Ahn feared for his life. He
that are transferred to the Department, except to the extent that a Department
component already has existing section 504 regulations.”).
9
See, e.g., U.S. House of Representatives, Committee on Homeland Security,
ICE Detention Facilities: Failing to Meet Basic Standards of Care (Sept. 21, 2020),
https://homeland.house.gov/imo/media/doc/Homeland%20ICE%20facility%20staff%20r
eport.pdf (finding that many detainees were “reluctant to raise mental health issues” for
fear of being placed in segregation, where mental health care is “lacking”).

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Choung Woong Ahn

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stated, “I get the coronavirus, I could die. And there are lots of people here.
So I am scared.” On April 10, he joined a hunger strike occurring in his
dormitory, and began refusing meals to protest the conditions at Mesa
Verde.
In April 2020 during a mental health appointment, Mr. Ahn reported to a
psychologist that he had feelings of sadness and low energy, as well as
trouble sleeping. The psychologist concluded that Mr. Ahn had an
unspecified depressive disorder and referred him to a psychiatrist. Later
that same month, Mr. Ahn informed the medical staff that he had attempted
suicide at least three different times in custody in 2014, 2015, and 2019.
On April 30, 2020 during one of his “talk therapy” sessions, Mr. Ahn
reported that his depression was “6-7/10 (10 being the worst).” He
expressed feelings of anxiety and not “want[ing] to live in this life .” When
asked, Mr. Ahn denied suicidal ideations, but noted that he was awaiting a
“decision regarding his deportation,” and “when he is to the point of
deportation” he might have thoughts “of wanting to die.”
As the pandemic intensified and his physical and mental health
deteriorated, Mr. Ahn submitted at least four requests for release through
his lawyers, all of which were denied (including one by voicemail). On the
day before his next hospitalization, witnesses in his dormitory noted that he
cried and seemed abnormally quiet upon learning that his latest release
request had been denied, commenting that he would never get out of
detention. Multiple witnesses expressed that Mr. Ahn’s mental and physical
state was well known among GEO employees and detainees alike.
On May 12, 2020, Mr. Ahn was admitted to Mercy Hospital in Bakersfield
due to chest pain. Throughout his detention at Mesa Verde, Mr. Ahn made
several medical requests due to persistent pain in his feet, his shoulder,
and his chest. He also complained that his diabetes and high blood
pressure medication were not refilled in a timely manner. On the day Mr.
Ahn was hospitalized, he was struggling to breathe, complaining of chest
pain, and had liquid coming out of his nose. According to witness
statements, detainees nearby asked the guards to help, while one guard
radioed for an hour, but no one showed up. Witnesses in the dormitory also
reported that when Mr. Ahn requested medical care, he frequently received
attention several days later or not at all. One witness recounted that in his

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Choung Woong Ahn

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experience, GEO employees did not take medical complaints seriously until
they saw someone seriously ill or near death.
2. ICE and GEO quarantined Mr. Ahn in solitary confinement,
despite his disabilities and history of suicide attempts.
Upon his return to Mesa Verde on May 14, 2020, Mr. Ahn was placed in an
isolation unit, ostensibly for purposes of medical quarantine, even though
he tested negative for COVID-19. At the time, public health experts warned
that ICE’s “practice . . . of locking people in conditions . . . equivalent to
punitive solitary confinement. . . as a form of ‘quarantine’ or ‘medical
isolation’” in response to the COVID-19 pandemic, as it subjected detained
people to “significant risk of grave harm (including harm that may be
permanent, even fatal).”10 Citing “widely accepted” scientific consensus,
experts explained that “ICE detainees with pre-existing mental illness or
emotional impairment are especially at risk”; when “placed in conditions
that are the equivalent of solitary confinement” they are “especially likely to
suffer an exacerbation of their psychiatric disability,” rendering them “even
more medically and psychologically vulnerable.”11
Experts have concluded that solitary confinement is by design an
“inappropriate, ill-conceived, and counter-productive” tool for quarantine.12
Among other things, detainees held in solitary often lack access to
adequate medical care and hygiene supplies “even more acute[ly]” than in
the general population, surfaces may be unsanitary, and without the use of
negative pressure rooms, the virus can still easily spread through airborne
transmission.13 As such, this practice ”very likely exacerbate[s] rather than
limit[s] or alleviate[s] the spread of COVID-19” in ICE facilities.14 Though
Mr. Ahn died before he could report conditions in his cell in detail, medical
professionals have specifically highlighted his case as illustrating how
“preemptive lockdowns” in a “solitary confinement” setting, “marked by
10

Declaration of Craig W. Haney, PhD., Fraihat v. ICE, No. 5:19-cv-01546-JGBSHK (C.D. Cal. June 24, 2020) (Dkt. 172-8) ¶¶ 5, 32 (hereinafter, Haney Dec.); see
also, e.g., id. ¶ 33 (“the scientific literature on the harmfulness of solitary confinement is
now widely accepted and the research findings are consistent and alarming.”).
11
Id. ¶ 5(D).
12
Id. ¶ 31.
13
Id. ¶ 18.
14
Id. ¶ 31.

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Choung Woong Ahn

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“extreme isolation and stark conditions,” pose “grave dangers to [detained
persons’] mental and physical health” and threaten “needless suffering and
loss of life.”15
Notably, at the time ICE and GEO purported to “quarantine” Mr. Ahn in
isolation, they were regularly accepting incoming transfers from California
prisons with confirmed outbreaks of COVID-19, directly into the dormitories
at Mesa Verde, without universally quarantining or regularly testing them.16
They continued doing so for months after Mr. Ahn’s death, until a federal
court ordered them to stop, finding that their inadequate testing and
quarantine protocols likely violated the Fifth Amendment rights of all
detainees.17
After being placed in solitary, Mr. Ahn informed the psychologist that he
had feelings of depression. Nevertheless, staff held him there. The records
show no consideration of any alternative housing placement.18
Mr. Ahn’s brother, Young Ahn, informed DRC that he spoke to his brother
at least once a day while he was in detention. Young stated that his brother
had not expressed suicidal ideation to him before he entered solitary
confinement, and believed that the extreme isolation had a detrimental
impact on his brother’s mental state.

15

Id. ¶ 46.
See, e.g., Joint Statement by the detained people at Mesa Verde (Aug. 6, 2020),
https://www.centrolegal.org/wp-content/uploads/2020/08/MV-COVID-19-OutbreakStatement.pdf (Mesa Verde detainees reporting that as of early August 2020, “new
people continued to arrive in our dorms, straight from prisons with massive COVID-19
outbreaks, without being quarantined or even tested for the virus”); Zepeda Rivas First
Preliminary Injunction (finding that ICE did not regularly quarantine or test detainees
transferred from COVID-19-infected prisons upon intake at Mesa Verde, but rather
brought them directly into dormitories); Zepeda Rivas v. Jennings, No. 20-CV-02731VC, 2020 WL 4554646, at *1 (N.D. Cal. Aug. 6, 2020) (finally ordering ICE to stop
incoming transfers to Mesa Verde).
17
Zepeda Rivas First Preliminary Injunction at *3 (further finding that ICE made “at
least one misrepresentation” to the court about this “matter of great importance.”).
18
Haney Dec., supra note 10, ¶ 13(E) (“The goals of quarantining or medically
isolating an individual can be met without placing them in dangerous conditions
equivalent to solitary confinement.”).
16

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Choung Woong Ahn

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3. After placing him in a setting known to exacerbate preexisting mental illness, ICE and GEO failed to intervene to
prevent his death.
On May 16, 2020, the day before Mr. Ahn died by suicide, a clinical
psychologist supported Young Ahn’s assertion and reported that Mr. Ahn
appeared to be at “high suicidal risk if deported.” On May 17, 2020, the
morning of his death, an attorney for Mr. Ahn emailed ICE, requesting that
they return him to his dormitory because isolation was proving detrimental
to his mental health. That same day, a different medical provider indicated
that Mr. Ahn’s mental illness was “severe” and again stated that Mr. Ahn
was at “high risk of suicide if deported.” In fact, Mr. Ahn faced the possibility
of being ordered deported in as little as two days, at his next scheduled
hearing on May 19, 2020. He remained unrepresented in his removal
proceedings, and had not prepared or filed any applications for relief to
remain in the United States.
On the evening of Sunday, May 17, 2020, Mr. Ahn was left unobserved in
his medical isolation room for at least a period of 18 minutes, according to
police and autopsy reports. During this period, he died by hanging himself
with a bedsheet. A witness familiar with the medical isolation area in which
Mr. Ahn died reported that he frequently saw guards performing rote,
perfunctory checks, often passing by the segregation unit without knocking
on the door or looking through the window of the cell, but simply scanning a
key fob at various points. This statement echoes reports by detainees at
other facilities, and supports a public health expert’s assessment that
“superficial and pro forma” checks and “monitoring by security staff” at the
Adelanto facility were one of many “lockdown practices” that exposed
detainees to significant risks of harm there.19

19

See Haney Dec., supra note 10, ¶ 26; Declaration of Ruben Dario Mencias Soto,
Fraihat v. ICE, No. 5:19-cv-01546-JGB-SHK (C.D. Cal. June 24, 2020) (Dkt. 187) ¶ 13
(detainee at Adelanto recounting that after potential COVID-19 exposure he was locked
down 23 hours a day with insufficient medical care and monitoring by mental health
staff, and describing checks as follows: “The rest of the day, the security staff comes by
every 15 minutes. They have a little electronic tube that they hit on the door but I have
observed that the do not look inside the cell to make sure we are okay. I am very
worried that . . . I will die without them noticing.”).

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In a Congressionally-mandated Detainee Death Report released following
Mr. Ahn’s death, ICE initially published false and misleading information,
describing Mr. Ahn’s mental status at the time of death as “essentially
normal.”20 After Mr. Ahn’s attorneys notified ICE that the report contained
false and misleading information, ICE deleted the phrase and published a
new report.21
III.

ICE and GEO discriminated against Mr. Ahn by segregating
him on the basis of his disabilities and by denying him
reasonable accommodations, violating federal disability law.
1. Segregation on the basis of disability.

Section 504 of the Rehabilitation Act prohibits disability discrimination in
any program or activity conducted by an executive agency or entity that
receives federal funding, which includes GEO.22 DHS has adopted and
implemented Section 504’s prohibitions as binding regulations to combat
disability discrimination.23 Section 504 and ICE’s own standards state that
any individual with a disability must enjoy an “equal opportunity to
participate in, access, and enjoy the benefits of the facility’s programs,
services, and activities” in the least restrictive and most integrated setting
possible.24 Additionally, Section 504, as well as Supreme Court precedent,
provide that placing an individual with a disability in a restrictive
environment on the basis of that disability constitutes prohibited
discrimination. 25 In this case, Mr. Ahn was placed in medical segregation
because of his disabilities even though ICE well knows that segregation

20

See Rebecca Plevin, ‘This death was preventable’: Family asks state to probe
74-year-old’s suicide in ICE detention, Desert Sun (Aug. 7, 2020)
https://www.desertsun.com/story/news/politics/immigration/2020/08/07/family-asksnewsom-probe-choung-woohn-ahn-suicide-ice-mesa-verde/5504694002/ (linking to two
versions of reports).
21
See id.
22
See 29 U.S.C. § 794.
23
See generally 6 C.F.R. § 15.
24
See 6 C.F.R. § 15.30; 2011 Performance-Based National Detention Standards
(PBNDS) 4.8 at 345.
25
See Olmstead v. L.C., 527 U.S. 581 (1999).

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Choung Woong Ahn

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settings can exacerbate existing mental illnesses, contribute to overall
mental deterioration, and even lead to suicide.26
First, placement in solitary-like conditions was unnecessarily restrictive.
Generally, “psychologically vulnerable detainees should be excluded from
all forms of severe social isolation, where they are “particularly likely to
decompensate, suffer worsening depression, and much more frequently
engage in self-harming and suicidal behavior in response to social
isolation.”27 Thus, although CDC quarantine guidelines developed for the
general population recommend that individuals with confirmed or supposed
cases of COVID-19 self-isolate at home, public health experts explain that
these guidelines apply differently in the detention context. Specifically, to
best prevent the spread of COVID-19 in detention, “ICE must avoid the use
of lockdown procedures with detainees who suffer pre-existing mental
health conditions unless they are absolutely necessary.”28 “Only those
persons who have confirmed or suspected cases of COVID-19” should
even be considered for medical isolation.29 And even a suspected
26

See, e.g., Civil Rights Education and Enforcement Center, et. al., Complaint for
violations of civil, constitutional, and disability rights of Anderson Avisai Gutierrez
(March 13, 2020), https://www.splcenter.org/sites/default/files/2020-0313 anderson avisai gutierrez crcl 504 complaint .pdf (describing cases of detainees
who died by suicide following improper placement in segregation); Memorandum from
DHS CRCL to ICE regarding Adelanto Correctional Facility Complaints (April 25, 2018),
https://www.pogo.org/document/2019/09/dhs-office-for-civil-rights-and-civil-libertiesreview-of-adelanto-sent-to-ice-in-april2018/#document/p47/a520498%20(finding%20%22Detainees%20with%20serious%20
mental%20health at 5 (”Detainees with serious mental disorders should only be housed
in administrative segregation as a last resort, as that environment is not conducive to
improving mental health status”); Memorandum from Ellen Gallagher, Senior Policy
Advisor, DHS CRC. to Deputy Secretary Mayorkas, DHS (July 23, 2014) at 3 (stating
that placing individuals in ICE custody who suffer from serious mental health conditions
into segregated settings is non-therapeutic and
“imposes improper punitive conditions, and subjects vulnerable detainees to physical
and mental deterioration”); JD Strong et al., The body in isolation: The physical health
impacts of incarceration in solitary confinement, PLOS ONE, Oct. 9, 2020,
https://doi.org/10.1371/journal.pone.0238510. (explaining that “solitary confinement is
associated not just with mental, but also with physical health problems” and “analyz[ing]
a range of physical exacerbated by both restrictive conditions and policies.”).
27
Haney Dec., supra note 10, ¶ 34.
28
Id. ¶ 43.
29
See Haney Dec., supra note 10, ¶ 34 (emphasis added).

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Choung Woong Ahn

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diagnosis of COVID-19 may weigh towards release for medical care in the
community rather than placement in solitary confinement, since solitary
confinement likely “will increase the risk in the facility from COVID-19.” 30
Here, ICE and GEO knew that Mr. Ahn had neither a confirmed nor
suspected case of COVID-19, and that placing him in isolation would
exacerbate his disabilities. Mr. Ahn received a negative COVID-19 test
result after discharge from the hospital; yet, ICE and the GEO Group still
placed him in segregation without adequately considering any alternative
housing option, let alone release.31 Mr. Ahn verbally expressed to staff that
he had feelings of anxiety, loneliness, and depression, and one of his
lawyers emailed ICE on the morning of his death requesting placement in
the dormitory. But he did not receive enhanced treatment or screening,
periodic assessment of his mental health status, or evaluation by medical
staff for disability-related accommodations. ICE and GEO continued to
segregate Mr. Ahn due to his disabilities.
ICE and GEO failed to provide Mr. Ahn with equal access to participate in
the same programs, services, and activities as the general population.
Because staff were aware of Mr. Ahn’s disabilities and negative COVID-19
test result, a reasonable modification that allowed Mr. Ahn to engage in the
same activities as the general population, while maintaining the
recommended social distancing, should have been considered and
implemented.

30

Id. ¶ 31. This is because solitary confinement, when operated without a negative
pressure system, does not effectively stop transmission of the virus, and because
detainees will likely under-report symptoms for fear of being placed in solitary. See
Declaration of Lauren Brinkley-Rubinstein, Arriaga v. Decker, No. 20-cv-003600
(S.D.N.Y. May 29, 2020) (Dkt. 33-4) ¶ 23; see also Community Honors Memory of
Choung Woong Ahn, https://www.centrolegal.org/community-honors-memory-ofchoung-woong-ahn/ (May 21, 2020) (Mr. Ahn’s dormmate reporting, “given what
happened, now others do not want to go to Medical because they are scared.”).
31
Mr. Ahn had previously requested release on humanitarian parole, which ICE
denied by voicemail with no written or reasoned analysis.

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2. Failure to ensure adequate screening to identify, track, and
provide reasonable accommodations for people with
disabilities.
ICE and GEO routinely fail to adequately identify, track, and provide
accommodations for detained individuals with disabilities as required by
Section 504.32 Inadequate screening procedures result in the failure to
identify individuals with disabilities, track their needs, and provide
necessary accommodations for their disabilities. In this case, ICE and GEO
failed to engage in an adequate individualized assessment to determine
Mr. Ahn’s disabilities and what accommodations were needed for his care.
According to ICE’s own standards, “upon change of custody to ICE/ERO
from federal, state or local custody, ICE/ERO staff or designee shall inquire
into any known prior suicidal behaviors or actions, and, if behaviors or
actions are identified, shall ensure detainee safety pending evaluation by a
medical provider. The patient’s ‘medical summary report’ shall be
transferred to ICE.”33 Then, “At the time of screening staff should assess
relevant available documentation as to whether the detainee has been a
suicide risk in the past, including during any prior period of detention or
incarceration.”34
The records show no inquiry by ICE and GEO into past suicidal behaviors
at Solano State Prison, no adequate medical history review, and no
adequate individualized determination of Mr. Ahn’s needs upon intake to
Mesa Verde, violating Section 504 and ICE’s Performance Based National
Standards 2011 (PBNDS 2011). For example, a mental health “receiving
screening” dated February 21, 2020 failed to note any prior
hospitalizations, prior mental health treatment, past suicide attempts, past
prescription of medication, or past signs of depression or anxiety—and
included no referral for mental health care. Given Mr. Ahn’s history of
suicide attempts in Solano State Prison, including as recently as 2019, staff
should have carefully reviewed previous incarceration records when
screening him at Mesa Verde. But Mr. Ahn’s detention file does not show
what, if any, records Mesa Verde staff reviewed, or what information they
32
33
34

See 6 C.F.R. § 15.30
PBNDS 2011 4.6(G)(1).
PBNDS 2011 4.6(V)(B)(2).

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relied on, to support their determination that Mr. Ahn had no disabilities and
no history of mental illness, and did not require any treatment. In sum, the
screening process did not reflect any reasoned individualized assessment
of whether Mr. Ahn had any disabilities that required accommodation.
ICE and GEO’s failure to adequately screen for and timely identify Mr.
Ahn’s mental illness led to his placement in housing that was dangerous
and detrimental to his health. As such, ICE and GEO failed to provide Mr.
Ahn with reasonable accommodations for his disabilities that would have
allowed him to access adequate medical care and appropriate housing,
violating federal disability law.
IV.

ICE and GEO violated Mr. Ahn’s Fifth Amendment substantive
due process rights.

The Fifth Amendment to the U.S. Constitution prohibits the government
actors and their contractors from subjecting civil detainees to conditions
that are in any way punitive, i.e. conditions that impose harm excessive to
the government’s interest, or that reflect “deliberate indifference” by
government officials to the detainee’s life and safety.35 The Fifth
Amendment also requires the government to ensure the “reasonable health
and safety” of people detained civilly.36 Courts have recognized that solitary
confinement in ICE detention facilities can exacerbate pre-existing mental
illnesses, and that improper placement in solitary confinement may reflect
deliberate indifference.37
35

See e.g., Jones v. Blanas, 393 F.3d 918, 932 (9th Cir. 2004) (punitive
conditions); Unknown Parties v. Johnson, No. CV-15-00250-TUC-DCB, 2016 WL
8188563, at *5 (D. Ariz. Nov. 18, 2016), aff'd sub nom. Doe v. Kelly, 878 F.3d 710 (9th
Cir. 2017) (condition punitive “if it imposes some harm to the detainee that significantly
exceeds or is independent of the inherent discomforts of confinement and is not
reasonably related to a legitimate governmental objective or is excessive in relation to
the legitimate governmental objective.”)
36
See, e.g., Hernandez Roman v. Wolf, No. 20-55436, 2020 WL 5683233, at *4
(9th Cir. Sept. 23, 2020) (reasonable health and safety) (citing DeShaney v. Winnebago
County Dep't of Soc. Servs., 489 U.S. 189, 199-200 (1989)).
37
See Disability Rts. Mont. Inc. v. Batista, 930 F.3d 1090, 1098 (9th Cir. 2019)
(holding that plaintiffs sufficiently pled factual allegations of deliberate indifference by
describing that defendants: denied inmates adequate mental health treatment; had a
pattern of placing mentally ill inmates in solitary confinement without significant mental
health care; and their improper responses increased the risk of suicide); see also

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For Mr. Ahn, solitary confinement was punitive—indeed, a death sentence.
ICE and GEO exposed Mr. Ahn to a high risk of harm by intentionally
placing him in conditions of extreme isolation and deprivation, despite
knowing that it would exacerbate his pre-existing mental illnesses—while
also failing to provide him adequate mental health treatment or properly
monitor him. As referenced above, the day before Mr. Ahn died by suicide,
a clinical psychologist at Mesa Verde warned that Mr. Ahn was
experiencing sadness, trouble sleeping, low energy, and appeared to be at
“high suicidal risk if deported.” Experts have described the psychological
torture that Mr. Ahn was likely suffering in solitary confinement.38 Though
he was on the verge of an urgent mental health crisis, ICE and GEO did not
attempt to improve or alleviate Mr. Ahn’s situation. Hours before Mr. Ahn’s
death, another psychologist reported that Mr. Ahn’s mental illness was
“severe” and echoed that he was at “high suicide risk if deported.” In
response, ICE and GEO took no steps to intervene, and also failed to
adequately monitor him. He took his life later that day. In the
circumstances, ICE and GEO placed Mr. Ahn at a high risk of harm.
ICE had no legitimate interest in segregating Mr. Ahn. He tested negative
for COVID-19, and in any event, as explained above, solitary confinement
does not effectively prevent the spread of COVID-19 in detention.
Moreover, at the same time they placed Mr. Ahn in solitary confinement,
ICE and GEO were accepting incoming transfers to Mesa Verde from state
prisons with confirmed outbreaks of COVID-19 without universally
quarantining or testing new intakes.39 Overall, ICE and GEO exposed Mr.
Ahn to an excessive risk of harm, amounting to punishment in violation of
the Fifth Amendment.

Braggs v. Dunn, 257 F. Supp. 3d 1171, 1192 (M.D. Ala. 2017); Finley v. Huss, 723 Fed.
Appx. 294, 298 (6th Cir. 2016).
38
See Medical Consensus Statement at 214 (arguing that “psychological and
physical consequences” of solitary confinement “raise serious questions about its . . .
status as a form of torture”); Haney Dec. ¶ 10 (describing ICE detention centers as
“extremely stressful environments for the persons confined in them,” and
“psychologically and medically harmful in their own right”); Section VII infra (describing
recent case of detained person at Mesa Verde held in solitary confinement in intake cell
in conditions the UN defines as torture).
39
See supra note 16.

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ICE and GEO also showed deliberate indifference to Mr. Ahn’s life by
quarantining him in solitary confinement, in violation of the Fifth
Amendment. By placing him in isolation with environmental hazards and in
conditions of extreme social isolation, and then also not observing him as
required under their own standards (as detailed below), ICE and GEO left
him “in a situation that [is] more dangerous than the one in which [they]
found him,” affirmatively placing him in danger, and amounting to
punishment in violation of the Fifth Amendment.40 For these same reasons,
ICE and GEO failed to provide conditions of “reasonable health and safety.”
V.

ICE and GEO repeatedly violated their own detention
standards, leading to Mr. Ahn’s death.

Both ICE and GEO are obligated to follow PBNDS 2011. These national
standards are necessary to guide and shape facility practices to ensure the
safety and well-being of all detainees. Here, Mr. Ahn’s medical and
detention records suggest that ICE and GEO repeatedly violated the
PBNDS by failing to provide timely and adequate mental health treatment;
failing to provide timely and adequate medical care; failing to follow proper
screening protocols; failing to adequately assess risk of self-harm; failing to
abide by medical housing standards; and failing to implement suicide
prevention standards.
1. Failure to provide timely and adequate mental health treatment.
At a basic level, the PBNDS 2011 require access to a continuum of
adequate health care services, from screening and prevention through
treatment, as well as timely transport to a higher-level care facility when
needed.
Here, Mr. Ahn did not receive any adequate mental health evaluations or
treatment until more than two months after his arrival at Mesa Verde, and
he died by suicide 24 days later. Six days into Mr. Ahn’s “talk therapy”
40

Hernandez v. City of San Jose, 897 F.3d 1125, 1133 (9th Cir. 2018); see also
Complaint, Estate of Escobar Mejia v. Archambeault, et. al., No. 20-CV-2454 (S. D. Cal
Dec. 16, 2020) (alleging negligence, deliberate indifference to health and safety, and
wrongful death because ICE held Mr. Escobar Mejia, the first to die of COVID-19 in ICE
custody, in conditions that they “knew would expose him to a deadly disease.”).

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treatment, he reported to staff that he had feelings of depression, anxiety,
and not “want[ing] to live in this life.” Once ICE became aware of his
depression and history of suicide attempts, it was critically necessary to
provide Mr. Ahn with treatment beyond the scope of ordinary care. Yet, ICE
did not modify Mr. Ahn’s treatment in the slightest. It was wholly insufficient
to rely on basic talk therapy to ensure Mr. Ahn’s well-being. In sum, the
documents show significant failures to provide proper treatment and
escalate to higher levels of care, violating the PBNDS. Especially in light of
the “longstanding pattern of frequent and severe deficiencies” in mental
health care in ICE detention, CRCL and OIG should immediately
investigate the inadequate mental health care leading to Mr. Ahn’s death.41
2. Failure to provide timely and adequate medical care.
Under PBNDS 2011 4.3 (II)(4), “detainees shall be able to request health
services on a daily basis and shall receive timely follow up.” While at Mesa
Verde, Mr. Ahn’s medical treatment was either (1) significantly delayed or
41

See, e.g., American Immigration Council, Failure to provide adequate medical
and mental health care to individuals detained in the Denver Contract Detention Facility
(June 4, 2018)
https://www.americanimmigrationcouncil.org/sites/default/files/general litigation/complai
nt demands investigation into inadequate medical and mental health care conditio
n in immigration detention center.pdf; Human Rights First, Prisons and Punishment:
Immigration Detention in California (Jan. 2019),
https://www.humanrightsfirst.org/sites/default/files/Prisons and Punishment.pdf;
Human Rights Watch, et al., Code Red: The Fatal Consequences of Dangerously
Substandard Medical Care in Immigration Detention (2018),
https://www.hrw.org/report/2018/06/20/code-red/fatal-consequences-dangerouslysubstandard-medical-careimmigration#; American Civil Liberties Union, et al., Fatal
Neglect: How ICE Ignores Deaths in Detention (Feb. 2016),
https://www.aclu.org/sites/default/files/field document/fatal neglect acludwnnijc.pdf;
Southern Poverty Law Center, Shadow Prisons: Immigrant Detention in the South,
(Nov. 2016), https://www.splcenter.org/20161121/shadow-prisons-immigrant-detentionsouth; Disability Rights California, There Is No Safety Here: The Dangers for People
with Mental Illness and Other Disabilities in Immigration Detention at Geo Group’s
Adelanto ICE Processing Center (Mar. 2019),
https://www.disabilityrightsca.org/system/files/fileattachments/DRC REPORT ADELANTO-IMMIG DETENTION MARCH2019.pdf;
Disability Rights California, Otay Mesa Detention Center: Inhumane Conditions and the
Harsh Reality of ICE’s Civil Detention System (Nov. 2020),
https://www.disabilityrightsca.org/system/files/file-attachments/OM-Report-Final.pdf.

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(2) categorically nonexistent. Mr. Ahn made multiple patient health requests
for a variety of medical concerns, including swollen feet & shoulder pain;
however, Mr. Ahn only received one documented follow-up with a medical
provider. As noted above, witnesses corroborated that Mr. Ahn did not
receive timely follow-ups to his medical requests.
In addition, following his March 2020 hospitalization to remove a mass on
his lung, hospital records indicated that he needed to return for follow up
care and to receive biopsy results. Mr. Ahn understood that he had been
diagnosed with lung cancer. Yet ICE’s records suggest that over month
later, ICE had still not authorized a follow up visit. Two months after his
hospitalization, records indicated that the “earliest appointment is June 1.”
By this point, it was too late—Mr. Ahn was already dead.
Additionally, while at Mesa Verde, Mr. Ahn established a critically important
medication regimen for his diabetes, chest pain, and high blood pressure.
However, he was forced to remind staff to fill his prescriptions on time,
which again directly violated ICE’s Performance-Based Detention
Standards.42
3. Failure to adequately recognize risk of self-harm.
The PBNDS provide that a detained person “may be identified as being at
risk for significant self-harm/suicide at any time while in ICE custody. Staff
must therefore remain vigilant in recognizing and appropriately reporting
when a risk is identified.”43 Yet, staff did not remain vigilant in identifying
Mr. Ahn’s deteriorating mental condition. Far from it—Mr. Ahn repeatedly
expressed feelings of depression, anxiety, and low energy, and possible
suicidal ideation should he approach the “the point of” deportation.
Although staff twice documented a “high risk of suicidality if deported,” the
records reveal no analysis of what the phrase “if deported” meant, including
how imminent Mr. Ahn perceived his deportation to be. Thus, the records
reveal no way that staff could have accurately assessed Mr. Ahn’s risk of
self-harm.

42
43

PBNDS 2011 4.3 (II)(20).
PBNDS 2011 4.6 (V)(B)(3).

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In addition, “where a detainee has a serious . . . mental health condition . . .
staff shall complete a Medical/Psychiatric Alert form . . . and file the form in
the detainee’s medical record.”44 The PBNDS lists “suicidal behavior or
tendencies” as a condition “meriting the completion” of such an alert. Mr.
Ahn’s medical records do not contain psychiatric alerts. Moreover, the
medical records do not show any escalation of these concerns to higherlevel staff, or document any clinical deliberation as to whether Mr. Ahn
should or should not have been placed in solitary confinement or on suicide
watch, in light of his risk of self-harm. These were clear warning signs by
themselves, but Mesa Verde staff should have been especially concerned
and vigilant given Mr. Ahn’s known mental health history, including three
prior suicide attempts in detention settings.
Shortly after Mr. Ahn’s death, on the evening of May 17, 2020, a GEO
Group employee stated to a police officer responding to the scene that Mr.
Ahn had not been on suicide watch, though the employee was aware that
Mr. Ahn had spoken with a psychiatrist the day before and was “possibly
depressed.” Far from “possibly depressed,” as noted above, a medical
provider earlier that actually described Mr. Ahn’s mental illness as “severe,”
and found him to be a “high risk” of suicide. In these circumstances, ICE
and GEO failed to be “vigilant” and take “appropriate” steps to recognize
the real risk of harm facing Mr. Ahn. To the extent he was not on suicide
watch as the GEO employee suggested, he should have been.
4. Violation of medical housing standards.
“Prior to placing a mentally ill detainee in medical housing, a determination
shall be made by a medical or mental health professional that placement in
medical housing is medically necessary.”45 Mr. Ahn’s medical and detention
records show no individualized assessment by a clinician that placement in
medical isolation upon return from the hospital was necessary.
5. Violation of Suicide Prevention Standards.
Given that ICE and GEO were aware of his history of self harm in
detention, Mr. Ahn should have been under constant 1:1 observation.
44
45

PBNDS 2011 4.3(M).
PBNDS § 4.3(F)(3)(a).

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According to ICE’s Suicide Standards, “Suicidal detainees will be monitored
by assigned security officers who maintain constant one-to-one visual
observation, 24 hours a day, until the detainee is released from suicide
watch. The assigned security officer makes a notation every 15 minutes on
the behavioral observation checklist.”46 However, Mr. Ahn did not receive
24-hour supervision. In fact, during the period in which he died, Mr. Ahn
was left alone for approximately 18 minutes, according to autopsy reports.
That is a strikingly inappropriate amount of time for an individual described
as a “high suicide risk,” and clearly violates ICE’s own detention standards.
VI.

ICE initially reported false and misleading information about
Mr. Ahn’s death, underscoring the need for independent
investigation, oversight and account.

As detailed above, Mesa Verde staff knew of Mr. Ahn’s mental illness and
history of suicide attempts, even describing him as a “high suicidal risk” on
the day before his death. Nevertheless, in a Congressionally-mandated
Detainee Death Report released following Mr. Ahn’s death, ICE described
his mental status at the time as “essentially normal.”47 After Mr. Ahn’s
attorneys notified ICE that the report contained false and misleading
information, ICE deleted the phrase and published a new report.48 Indeed,
ever since Congress required in 2018 that ICE publicly release reports on
in-custody deaths, ICE has a history of releasing incomplete, inaccurate
death reports that lack a meaningful review of what led to the deaths.49 As
multiple federal courts have now recognized in the context of the COVID-19
pandemic, ICE cannot be trusted to meaningfully investigate itself.50 And
46

ICE/DRO Detention Standard, Suicide Prevention and Intervention, Housing and
Monitoring – Constant Observation (F), IMMIGRATION AND CUSTOMS ENFORCEMENT, Dec.
2, 2008, available at: https://www.ice.gov/doclib/dro/detentionstandards/pdf/suicide prevention and intervention.pdf.
47
Plevin, This death was preventable, supra note 20.
48
See id.
49
See, e.g., ICE Releases Sham Immigrant Death Reports As It Dodges
Accountability And Flouts Congressional Requirements (Dec. 19, 2018),
https://immigrantjustice.org/press-releases/ice-releases-sham-immigrant-death-reportsit-dodges-accountability-and-flouts.
50
See note 3 supra (citing cases); see also Letter from U.S. House of
Representatives Committee on Oversight and Reform to DHS CRCL (Dec. 23, 2019),
https://oversight.house.gov/sites/democrats.oversight.house.gov/files/2019-1223.JR%20to%20DHS%20CRCL%20re%20ICE.pdf (requesting information from CRCL

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“because there is limited transparency and public accountability regarding
many aspects of detainee care” at Mesa Verde, an independent and
comprehensive investigation is necessary.51
VII.

Mr. Ahn’s death illustrates a larger pattern: ICE
disproportionately misuses solitary confinement against
detainees with disabilities and other vulnerable groups,
especially during the COVID-19 pandemic.

Further demonstrating the need for an independent investigation, reports
by detainees at Mesa Verde, together with recent litigation, media reports,
congressional findings, and the newest and most expansive empirical study
on the subject to date suggest that Mr. Ahn’s death reflects a much deeper
systemwide problem: ICE and their contractors have routinely abused
medical isolation, disproportionately harming the most vulnerable
detainees—such as people with disabilities and Black migrants—especially
during the COVID-19 pandemic.
Following Mr. Ahn’s death, his dorm mates at Mesa Verde staged
additional hunger strikes to protest the “mortal danger” posed by conditions
there, highlighting that a detainee was placed in “solitary confinement cell
for hours without any medical care.”52 Nevertheless, ICE and GEO
continued to improperly subject detainees with disabilities to solitary
confinement at Mesa Verde, ostensibly for purposes of medical isolation.
Alton Edmondson, a Black detainee who has asthma, kidney issues, and a
neurodevelopmental disability, was held in isolation for three weeks,
including seven days in a windowless intake cell with no bed for up to 23
hours per day, in blatant violation of detention standards, and in conditions
that the United Nations defines as torture.53 Despite his known disabilities,
regarding “gross negligence” in medical care in ICE facilities that led to a death by
suicide, among other things, and expressing concern that “no action was taken by ICE .
. . to remedy the inadequacies that led to these horrific incidents”).
51
American Immigration Council, Failure to provide adequate medical and mental
health care, supra note 41, at 4.
52
Joint Statement by the detained people at Mesa Verde (Aug. 6, 2020),
https://www.centrolegal.org/wp-content/uploads/2020/08/MV-COVID-19-OutbreakStatement.pdf.
53
See Farida Jhabvala Romero, ICE Misusing Solitary Confinement for COVID-19
Quarantine, Detainees Say, KQED (Oct. 6, 2020)

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he was also deprived of food in compliance with his religious diet, access to
medical care, reasonable access to his family and attorney, and access to
other amenities available to the general population—even though he
repeatedly tested negative for COVID-19, and could have been placed in
the dorms. In addition, he had blood in his urine for four months and was
told he required specialty care, but never was given an appointment. ICE
and GEO repeatedly changed their justification for placing him in solitary,
and never supplied an explanation supported by facts.
Meanwhile, federal courts are recognizing the need for oversight. A federal
district court recently issued a nationwide Preliminary Injunction, finding
that systemwide conditions in ICE detention during the COVID-19
pandemic likely violated Section 504 and the Fifth Amendment rights of
detainees with disabilities.54 Concerned that conditions in ICE detention
continue to subject class members with disabilities to a “substantial risk of
death,” the court ordered ICE to “mandate that medical isolation and
quarantine remain distinct from solitary, segregated, or punitive housing.”55
In addition, a recent report by the House Committee on Homeland Security
found widespread misuse of segregation in ICE detention against
detainees with disabilities.56 The Committee decried widespread failures in
mental health care and specifically noted that ICE officials and contract
employees “diminished past suicide attempts.”57 Noting the deaths of
multiple detainees by suicide in segregation, the Committee particularly
highlighted the case of an individual, who, like Mr. Ahn, “could have been

https://www.kqed.org/news/11841120/ice-misusing-solitary-confinement-for-covid-19quarantine-detainees-say.
54
See Fraihat v. U.S. Imm. and Customs Enforcement 445 F. Supp. 3d 709 (C.D.
Cal. 2020).
55
See Fraihat v. U.S. Imm. and Customs Enforcement, Order Granting Motion to
Enforce, No. 5:19-cv-01546-JGB-SHK (C.D. Cal. Oct. 7, 2020) (Dkt. 240).
56
See U.S. House of Representatives, Committee on Homeland Security, ICE
Detention Facilities: Failing to Meet Basic Standards of Care (Sept. 21, 2020),
https://homeland.house.gov/imo/media/doc/Homeland%20ICE%20facility%20staff%20r
eport.pdf at 3, 17, 19-20 (finding widespread misuse of segregation in ICE detention,
and noting that “40 percent of those placed in segregation suffer from some form of
mental illness.”).
57
Id. at 17.

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saved,” but instead of “being treated with . . . medication” was “remanded
to segregation.”58
Another congressional report reviewed recent internal audits of Mesa
Verde “reveal[ing] a host of concerns regarding medical treatment that
have gotten worse over the past three years.”59 Turning to detainee deaths
in solitary confinement in ICE detention generally, the report found
“alarming similarities” between cases, including many of those present in
Mr. Ahn’s case— detainees “were placed in solitary confinement despite
having serious mental illnesses,” did not “receive recommended mental
healthcare,” and then “officers failed to properly monitor their cells.”60 The
OIG has also recently found that staff at a different facility failed to properly
monitor detainees in solitary confinement.61
Finally, a recent empirical study provided the first “systematic, nationally
representative analysis” of the use of solitary confinement placements in
ICE detention.62 In solitary confinement throughout ICE detention, the study
found, “cases involving individuals with mental illnesses are
overrepresented, more likely to occur without infraction, and to last longer,
compared to cases involving individuals without mental illnesses.”63 In
addition, migrants from Black-majority countries are overrepresented by a
58

Id. Mr. Ahn is the ninth person to die by suicide in immigration detention since
ICE began publicly reporting in-custody deaths in fiscal year 2018. See ICE Detainee
Death Reporting, https://www.ice.gov/detainee-death-reporting (accessed Feb. 25,
2021).
59
U.S. House of Representatives, Committee on Oversight and Reform and
Subcommittee on Civil Rights and Civil Liberties, The Trump Administration’s
Mistreatment of Detained Immigrants: Deaths and Deficient Medical Care by Staff
(Sept. 24, 2020),
https://oversight.house.gov/sites/democrats.oversight.house.gov/files/2020-0924.%20Staff%20Report%20on%20ICE%20Contractors.pdf at 24.
60
Id.
61
Department of Homeland Security, Office of Inspector General, Capping Report:
Observations of Unannounced Inspections of ICE Facilities in 2019 (July 7, 2020),
www.oig.dhs.gov/sites/default/files/assets/2020-07/OIG-20-45-Jul20.pdf.
62
See Konrad Franco, Caitlin Patler & Keramet Reiter, Punishing Status and the
Punishment Status Quo: Solitary Confinement in U.S. Immigration Prisons, 2013-2017
(April 27, 2020), https://osf.io/preprints/socarxiv/zdy7f/ (forthcoming in Punishment and
Society) (pre-print) (cited with permission of author)
63
Id. at 13-17.

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factor of 6.8 in solitary confinement when compared to the overall detained
population, “suggesting the possibility of racialized differential treatment.”64
VIII.

An independent, comprehensive investigation into violations
of the civil, constitutional, and disability rights of Mr. Ahn is
necessary to hold ICE and GEO accountable for breaking the
law, and to prevent additional needless suffering and death.

As described herein, Mr. Ahn was subjected to inadequate treatment and
discriminatory conditions while confined at Mesa Verde. Specifically, the
absence of appropriate treatment and the negligent use of administrative
segregation violated federal law under Section 504, Mr. Ahn’s constitutional
rights, and DHS policy. The evidence demonstrates that Mr. Ahn’s
disabilities were unconstitutionally minimized, ignored, and dismissed. The
conditions at Mesa Verde, combined with ICE and GEO’s gross
misconduct, tragically led to Mr. Ahn’s suicide. Yet, Mr. Ahn’s experience
was far from anomalous. His case illustrates a troubling pattern of failed
oversight by ICE and its contractors in detention facilities across the state
of California. Without swift and meaningful action by CRCL and the OIG,
more individuals with disabilities will face serious and irreparable harm
under DHS’s supervision.
For these reasons, DRC, Centro Legal, and CCIJ request that CRCL and
OIG:
(1) conduct an independent and comprehensive investigation into the
circumstances at Mesa Verde that resulted in Mr. Ahn’s death,
including an evaluation of medical and mental health care
provided to him, the tracking and accommodation of his
disabilities, and his placement in solitary confinement;
64

Id. at 13 (finding that while migrants from Black-majority countries collectively
represent only 3.64 percent of the population in ICE detention, 24.74 percent of solitary
confinement cases involve individuals from those countries); see also Jhabvala
Romero, ICE Misusing Solitary Confinement, supra note 16 (quoting study author Dr.
Caitlin Patler as stating,“There might be some really problematic racialized practices
happening within detention facilities where a situation involving a Black detained person
results in solitary confinement much more frequently than we would expect based on
their portion of the detained population.”).

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(2) conduct an independent and comprehensive investigation into the
use of segregation (administrative, medical, and disciplinary) at
Mesa Verde. The investigation should evaluate facility practices
regarding the purpose and duration of segregation, as well as
practices relating to medical and mental health assessments,
particularly during the COVID-19 pandemic;
(3) publish the results of your investigation so that Congress and the
state of California can take appropriate action to hold ICE and
GEO accountable for the violations of law that led to Mr. Ahn’s
death, address ongoing harms arising from the improper use of
solitary confinement in California facilities, and prevent future
deaths like Mr. Ahn’s.
Sincerely,

Richard Diaz, Staff Attorney 2
Richard.Diaz@disabilityrightsca.org
Pamila Lew, Senior Attorney
Pamila.Lew@disabilityrightsca.org
Liz Logsdon, Managing Attorney
Liz.Logsdon@disabilityrightsca.org
Zachary Brown, Law Clerk
Zachary.Brown@disabilityrightsca.org
DISABILITY RIGHTS CALIFORNIA
LEGAL ADVOCACY UNIT
350 S. Bixel Street, Ste. 290
Los Angeles, CA 90017

Complaint for Violations of Civil, Constitutional, and Disability Rights
Choung Woong Ahn

~~

Trevor Kosmo, Staff Attorney
tkosmo@centrolegal.org

Priya Patel, Supervising Attorney
ppatel@centrolegal.org

Susan Beaty, Staff Attorney
sbeaty@centrolegal.org

Elaina Vermeulen, Advocate
evermeulen@centrolegal.org
CENTRO LEGAL DE LA RAZA
IMMIGRANTS’ RIGHTS PROJECT
3400 E. 12th St.
Oakland, CA 94601

Lisa Knox, Legal Director
lisa@ccijustice.org
CALIFORNIA COLLABORATIVE FOR IMMIGRANT JUSTICE
530 Divisadero St. #808
San Francisco, CA 94117

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